3/7/2018 Adult Trauma Advances in (sometimes they are little adults) Pediatrics Alisa McQueen MD, FAAP, FACEP Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics Associate Professor of Pediatrics The University of Chicago The University of Chicago I have no re le vant financ ial re latio nships to disc lo se . Who is b le e ding ? F AST e xa mina tio n Ho w muc h a nd wha t Ho w muc h a nd wha t kind o f vo lume ? kind o f vo lume ? T XA T XA Ca n we Ca n we me dic a lly slo w me dic a lly slo w do wn b le e ding ? do wn b le e ding ? 1
3/7/2018 F AST e xa mina tio n F AST e xa mina tio n Da ma g e Co ntro l Da ma g e Co ntro l Re susc ita tio n Re susc ita tio n T XA T XA Ca n we T ra nse xa mic me dic a lly slo w Ac id (T XA) do wn b le e ding ? Wha t is F AST a nd why do we do it? T XA F AST : F o c use d Asse ssme nt with I s the re b lo o d in the a b do me n? So no g ra phy in T ra uma Unsta b le Sta b le DPL CT sc a n I nva sive Ra d ia tio n 2
3/7/2018 F AST : F o c use d Asse ssme nt with F AST : F o c use d Asse ssme nt with So no g ra phy in T ra uma So no g ra phy in T ra uma Adults: sta nda rd o f c a re Adults: sta nda rd o f c a re K ids? K ids: 10-15% F AST in Pe dia tric T ra uma F AST in Pe dia tric T ra uma Ho w suspic io us a re yo u fo r intra - Sub-analysis of children with a b do mina l injury? blunt abdominal trauma 20 PECARN EDs • F re q ue nc y o f F AST • F re q ue nc y o f CT • Misse d intra a b do mina l injury Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. Ve ry lo w L o w Mo de ra te Hig h Ve ry hig h Ve ry lo w L o w Mo de ra te Hig h Ve ry hig h (<1%) (1-5%) (6-10%) (11-50%) (>50%) (<1%) (1-5%) (6-10%) (11-50%) (>50%) 11 % 13 % 20 % 23 % 30 % 11 % 13 % 20 % 23 % 30 % 1.01 0.84 0.86 0.98 0.98 Ra te o f F AST inc re a se d a s RR o f CT de c re a se d the suspic io n fo r intra - sig nific a ntly fo r lo w- R mo de ra te suspic io n injurie s a b d o mina l injury inc re a se d whe n F AST pe rfo rme d Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. 3
3/7/2018 F AST in Pe dia tric T ra uma Whe n e xc lude d site # 1, e ffe c t o f F AST o n CT de c re a se d All c hildre n < 16 with b lunt a b do mina l tra uma Ha d to e xc lude b e c a use no t F AST / CT / pro c e dure s a t the e no ug h F AST pe rfo rme d disc re tio n o f tre a tme nt te a m F AST c o mpa re d with no F AST Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in Ca lde r B e t a l. F o c use d Asse ssme nt with So no g ra phy fo r T ra uma in c hildre n with b lunt a b do mina l tra uma : a he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224. F AST in Pe dia tric T ra uma F AST in Pe dia tric T ra uma 69 % ha d ne g a tive F AST Se nsitivity a nd 2188 pa tie nts Gra de 3+ live r/ sple e n injury spe c ific ity o f pe dia tric F AST 37.9% F AST I ntra -a b do mina l injury (mo re like ly with MVC, le ss like ly re q uiring inte rve ntio n hig hly va ria b le with fa lls o r a ssa ult) 56 % ha d ne g a tive F AST Ca lde r B e t a l. F o c use d Asse ssme nt with So no g ra phy fo r T ra uma in c hildre n with b lunt a b do mina l tra uma : a Ca lde r B e t a l. F o c use d Asse ssme nt with So no g ra phy fo r T ra uma in c hildre n with b lunt a b do mina l tra uma : a multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224. multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224. 975 c hildre n F AST in Pe dia tric T ra uma T ria l 465 460 Sta b le c hildre n with b lunt to rso No F AST F AST tra uma ra ndo mize d sta nda rd tre a tme nt vs F AST 52 % CT 54 % CT No diffe re nc e in CT ra te s Suspic io n fo r intra a b do mina l injury b e fo re / a fte r F AST No diffe re nc e in misse d injurie s No diffe re nc e in le ng th o f sta y CT a t tre a ting te a m disc re tio n Ho lme s JF e t a l. E ffe c t o f Ab do mina l U ltra so und o n Clinic a l Ca re , Outc o me s, a nd Re so urc e U se Amo ng Ho lme s JF e t a l. E ffe c t o f Ab do mina l U ltra so und o n Clinic a l Ca re , Outc o me s, a nd Re so urc e U se Amo ng Childre n with Blunt T o rso T ra uma . A Ra ndo mize d Clinic a l T ria l. JAMA 2017;317:2290-2296. Childre n with Blunt T o rso T ra uma . A Ra ndo mize d Clinic a l T ria l. JAMA 2017;317:2290-2296. 4
3/7/2018 Sho uld we a b a ndo n F AST in kids? Unsta b le kids we re no t inc lude d Sho uld we a b a ndo n F AST in kids? CT o b ta ine d a t disc re tio n o f the pro vide rs Ma yb e we ne e d to do it mo re Ma yb e we ne e d to do it b e tte r Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in Bre nke rt T E e t a l. Pe rito ne a l fluid lo c a liza tio n o n F AST e xa mina tio n in the pe dia tric tra uma pa tie nt. Ame ric a n he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32. Jo urna l o f E me rg e nc y Me dic ine 2017;35:1497-99 “The Lethal Triad” Damage Control Resuscitation and Permissive Hypotension T XA Hypothermia Acidosis Coagulopathy 5
3/7/2018 Da ma g e Co ntro l Surg e ry 1. Co ntro l he mo rrha g e 2. De c o nta mina te Da ma g e Co ntro l Re susc ita tio n 1. Pe rmissive hypo te nsio n 2. E a rly b lo o d pro duc ts o ve r sa line Re tro spe c tive study o f a dults “I f the pre ssure is ra ise d b e fo re with pe ne tra ting tra uma a nd the surg e o n is re a dy to c he c k hypo te nsio n ma na g e d with a ny b le e ding tha t ma y ta ke DCR a nd DCS pla c e , b lo o d tha t is so re ly ne e de d ma y b e lo st.’ ’ Sta nda rd fluid Re stric te d fluid -WB Ca nno n (150+ c rysta llo id) (<150 ml c rysta llo id) US Army Surg e o n 1918 Duke MD e t a l. Re stric tive fluid re susc ita tio n in c o mb ina tio n with da ma g e c o ntro l WB Ca nno n. T he pre ve ntive tre a tme nt o f wo und sho c k. JAMA 1918;70:618-621. re susc ita tio n: time fo r a da pta tio n. J T ra uma Ac ute Ca re Surg 2012;73:674-678. 6
3/7/2018 Hydro sta tic pre ssure Sta nda rd fluid Re stric te d fluid ma y disrupt c lo ts (a vg 2757ml) (a vg 129ml) Mo rta lity in OR: Mo rta lity in OR: Dilutio n o f 32% 9% c o a g ula tio n fa c to rs Mo rta lity in I CU: Mo rta lity in I CU: wo rse ns b le e ding 5% 12% Ove ra ll mo rta lity: Ove ra ll mo rta lity: I nfla mma to ry 37% 21% c a sc a de c o ntrib ute s to o rg a n fa ilure Duke MD e t a l. Re stric tive fluid re susc ita tio n in c o mb ina tio n with da ma g e c o ntro l re susc ita tio n: time fo r a da pta tio n. J T ra uma Ac ute Ca re Surg 2012;73:674-678. Blo o d vo lume va rie s b y a g e . Childre n c a n lo se up to 45% o f the ir b lo o d I nfa nts: 90 – 100 c c / kg vo lume b e fo re Yo ung c hildre n: 70 – 80 c c / kg b e c o ming Ado le sc e nts: 60– 65 c c / kg hypo te nsive . L imit iso to nic fluids a nd g ive b lo o d e a rly Childre n with We do n’ t kno w wha t tra uma tic b ra in injury the ta rg e t b lo o d ma y b e hypo te nsive . pre ssure sho uld b e We do n’ t kno w wha t the g o a ls in pe dia tric s sho uld b e 7
3/7/2018 T XA T ra ne xa mic Ac id (T XA) va sc ula r F ib rino lysis a c tiva te s injury during a nd c lo t c o a g ula tio n surg e ry b re a kdo wn T XA T XA De c re a se s ne e d fo r tra nsfusio n b y 1/ 3 T XA va sc ula r F ib rino lysis a c tiva te s injury during a nd c lo t c o a g ula tio n surg e ry b re a kdo wn T XA Co uld it wo rk fo r tra uma ? Effects of TXA on death, vascular occulsive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32. CRASH-2 CRASH-2 274 ho spita ls SBP < 90 SBP < 90 40 c o untrie s HR > 110 HR > 110 sic k tra uma 20,211 tra uma Risk fo r Risk fo r pa tie nts pa tie nts sig nific a nt sig nific a nt b le e ding b le e ding T XA Pla c e b o T XA Pla c e b o 10,096 10,115 14.5% 16% Prima ry o utc o me : mo rta lity fro m mo rta lity fro m de a th within 4 a ll c a use s a ll c a use s we e ks in ho spita l 8
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